A prospective multi-center study comparing the complication profile of modest systemic hypothermia versus normothermia for acute cervical spinal cord injury.

STUDY DESIGN: Prospective multi-center trial. OBJECTIVES: To characterize the complication profile associated with modest systemic hypothermia after acute cervical SCI in a prospective multi-center study. SETTING: Five trauma centers in the United States. METHODS: We analyzed data from a prospective, multi-center trial on the use of modest systemic hypothermia for acute cervical SCI. Patients with acute cervical SCI were assigned to receive modest systemic hypothermia (33 C) or standard of care medical treatment. Patients in the hypothermia group were cooled to 33 C and maintained at the target temperature for 48 h. Complication profile and the rate of complications within the first 6 weeks after injury were compared between the two groups. Multiple regression analysis was performed to determine risk factors for complications after injury. RESULTS: Fifty patients (hypothermia: 27, control: 23) were analyzed for this study. Median age was significantly lower in the hypothermia arm (39 vs 59 years, p = 0.02). Respiratory complications were the most common (hypothermia: 55.6% vs control: 52.2%, p = 0.81). The rate of deep vein thrombosis was not significantly different between the two groups (hypothermia: 14.8% vs control 17.4%, p = 0.71). The rate of complications was not statistically different between the two groups. CONCLUSION: In this prospective multi-center controlled trial, preliminary data show that modest systemic hypothermia was not associated with increased risk of complications within the first 6 weeks after acute cervical SCI. TRIAL INFORMATION: The study is registered on clinicaltrials.gov NCT02991690. University of Miami IRB (Central IRB) approval No.: 20160758. Emory University IRB #IRB00093786.

Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial.

BACKGROUND: Up to 30% of patients with cancer continue to suffer from pain despite aggressive supportive care. The present study aimed to determine whether cordotomy can improve cancer pain refractory to interdisciplinary palliative care. MATERIALS AND METHODS: In this randomized controlled trial, we recruited patients with refractory unilateral somatic pain, defined as a pain intensity (PI) ≥4, after more than three palliative care evaluations. Patients were randomized to percutaneous computed tomography-guided cordotomy or continued interdisciplinary palliative care. The primary outcome was 33% improvement in PI at 1 week after cordotomy or study enrollment as measured by the Edmonton Symptom Assessment Scale. RESULTS: Sixteen patients were enrolled (nine female, median age 58 years). Six of seven patients (85.7%) randomized to cordotomy experienced >33% reduction in PI (median preprocedure PI = 7, range 6-10; 1 week after cordotomy median PI = 1, range 0-6; p = .022). Zero of nine patients randomized to palliative care achieved a 33% reduction in PI. Seven patients (77.8%) randomized to palliative care elected to undergo cordotomy after 1 week. All of these patients experienced >33% reduction in PI (median preprocedure PI = 8, range 4-10; 1 week after cordotomy median PI = 0, range 0-1; p = .022). No patients were withdrawn from the study because of adverse effects of the intervention. CONCLUSION: These data support the use of cordotomy for pain refractory to optimal palliative care. The findings of this study justify a large-scale randomized controlled trial of percutaneous cordotomy. IMPLICATIONS FOR PRACTICE: This prospective clinical trial was designed to determine the improvement in pain intensity in patients randomized to either undergo cordotomy or comprehensive palliative care for medically refractory cancer pain. This study shows that cordotomy is effective in reducing pain for medically refractory cancer pain, and these results can be used to design a large-scale comparative randomized controlled trial that could provide the evidence needed to include cordotomy as a treatment modality in the guidelines for cancer pain management.

PulseRider treatment of an anterior communicating artery aneurysm.

We present a case of a patient with an anterior communicating artery aneurysm treated by PulseRider-assisted coil embolization. PulseRider is a new device, FDA approved for treatment of broad-necked aneurysms of the basilar apex or internal carotid artery terminus. The aneurysm was broad-necked and involved the anterior communicating artery and was considered for traditional stent-assisted coiling as well as PulseRider-assisted coiling. The authors present the treatment plan and strategy and then fluoroscopic recording of the PulseRider delivery and subsequent coiling phase. Nuances of technique for this new device used in a challenging setting are discussed.The video can be found here: https://youtu.be/ont7ggqgLH8.

Subcentimeter epilepsy surgery targets by resting state functional magnetic resonance imaging can improve outcomes in hypothalamic hamartoma.

OBJECTIVE: The purpose of this study is to investigate the outcomes of epilepsy surgery targeting the subcentimeter-sized resting state functional magnetic resonance imaging (rs-fMRI) epileptogenic onset zone (EZ) in hypothalamic hamartoma (HH). METHODS: Fifty-one children with HH-related intractable epilepsy received anatomical MRI-guided stereotactic laser ablation (SLA) procedures. Fifteen of these children were control subjects (CS) not guided by rs-fMRI. Thirty-six had been preoperatively guided by rs-fMRI (RS) to determine EZs, which were subsequently targeted by SLA. The primary outcome measure for the study was a predetermined goal of 30% reduction in seizure frequency and improvement in class I Engel outcomes 1 year postoperatively. Quantitative and qualitative volumetric analyses of total HH and ablated tissue were also assessed. RESULTS: In the RS group, the EZ target within the HH was ablated with high accuracy (>87.5% of target ablated in 83% of subjects). There was no difference between the groups in percentage of ablated hamartoma volume (P = 0.137). Overall seizure reduction was higher in the rs-fMRI group: 85% RS versus 49% CS (P = 0.0006, adjusted). The Engel Epilepsy Surgery Outcome Scale demonstrated significant differences in those with freedom from disabling seizures (class I), 92% RS versus 47% CS, a 45% improvement (P = 0.001). Compared to prior studies, there was improvement in class I outcomes (92% vs 76%-81%). No postoperative morbidity or mortality occurred. SIGNIFICANCE: For the first time, surgical SLA targeting of subcentimeter-sized EZs, located by rs-fMRI, guided surgery for intractable epilepsy. Our outcomes demonstrated the highest seizure freedom rate without surgical complications and are a significant improvement over prior reports. The approach improved freedom from seizures by 45% compared to conventional ablation, regardless of hamartoma size or anatomical classification. This technique showed the same or reduced morbidity (0%) compared to recent non-rs-fMRI-guided SLA studies with as high as 20% permanent significant morbidity.

Readmission and complications within 30 days after intrathecal baclofen pump placement.

AIM: To describe 30-day outcomes after intrathecal baclofen (ITB) pump placement in children and identify risk factors for readmission, reoperation, and perioperative complication using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database. METHOD: Patients aged 0 to 18 years who underwent ITB pump placement (2012-2014) comprised the study cohort defined in the database. Multivariate regression analysis was performed using preoperative and perioperative data from the American College of Surgeons' NSQIP-P database. Outcomes of interest within 30 days of surgery were (1) unplanned reoperation; (2) unplanned readmission; and (3) composite postoperative event, including complication, reoperation, and/or readmission. RESULTS: We identified 423 surgeries; 246 (58.2%) patients were male, 177 (41.8%) patients were female. Median age was 12 years and 11 months. Median operative time was 70 minutes (interquartile range 56-97min). Mean length of stay was 3.8 days. The patient population had a high number of medical comorbidities. The overall readmission rate was 7.3%; mean postoperative admission date was 14.1 days after surgery. Of readmitted patients, 64.5% underwent reoperation. The most common indication for reoperation was surgical site infection. Female sex was associated with decreased risk of readmission (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.09-0.65; p=0.01); American Society of Anesthesiologists Classification of greater than or equal to 3 was associated with decreased risk of unplanned return to surgery (OR 0.26, 95% CI 0.11-0.66; p=0.04); length of stay greater than or equal to 3 days at index surgery was associated with increased risk of composite 30-day perioperative event (OR 2.33, 95% CI 1.29-4.20; p=0.01). INTERPRETATION: Our data provide national perspectives on 30-day perioperative outcomes for ITB pump placement in children. Results illustrate NSQIP-P database collection methodology and highlight opportunities for quality improvement in clinical practice. WHAT THIS PAPER ADDS: Seven percent of patients who underwent intrathecal baclofen pump placement required readmission within 30 days. The most common indication for reoperation was surgical site infection.

Thirty-day outcomes in pediatric epilepsy surgery.

PURPOSE: The aim of this study was to use the multicenter American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) to evaluate and identify risk factors for 30-day adverse events in children undergoing epilepsy surgery. METHODS: Using the 2015 NSQIP-P database, we identified children (age 0-18 years) undergoing pediatric epilepsy surgery and analyzed NSQIP-defined complications, unplanned reoperations, and unplanned readmissions. Multivariable logistic regression analysis was performed using perioperative data to identify risk factors for adverse events within 30 days of the index procedure. RESULTS: Two hundred eight pediatric patients undergoing epilepsy surgery were identified for the year 2015 in the NSQIP-P database. The majority of patients were male (51.8%) and white (72.9%). The median age was 10 years. Neurological and neuromuscular comorbidities were seen in 62.5% of patients. Surgical blood loss and transfusion was the most common overall NSQIP-defined event (15.7%) and was reported in 40% with hemispherectomy. Nineteen patients (6.8%) had an unplanned reoperation and 20 patients (7.1%) had an unplanned readmission. Multivariable logistic regression analysis showed that African American patients (OR 3.26, 95% CI 1.29-8.21, p = 0.01) and hemispherectomy (OR 3.05, 95% CI 1.4-6.65, p = 0.01) were independently associated with NSQIP-defined complications. Patients undergoing hemispherectomy (OR 4.11, 95% CI 1.48-11.42, p = 0.01) were also at significantly higher risk of unplanned readmission after pediatric epilepsy surgery. CONCLUSIONS: Data from the 2015 NSQIP-P database showed that hemispherectomy was significantly associated with higher perioperative events in children undergoing epilepsy surgery. Quality improvement initiatives for hemispherectomy should target surgical blood loss and wound-related complications. Racial disparities in access to cranial pediatric epilepsy surgery and perioperative complications were also highlighted in the present study.

Use of Spinal Cord Diffusion Tensor Imaging to Quantify Neural Ablation and Evaluate Outcome after Percutaneous Cordotomy for Intractable Cancer Pain.

BACKGROUND: Up to 20% of patients experience only partial pain relief after percutaneous cordotomy for cancer pain. OBJECTIVE: To determine whether diffusion tensor imaging (DTI) can quantify neural ablation and help evaluate early postoperative outcomes after cordotomy. METHODS: Patients undergoing percutaneous CT-guided cordotomy for intractable cancer pain were prospectively studied. Pre- and postoperative assessment was made using the visual analog scale (VAS) on pain and the pain severity scores of the Brief Pain Inventory Short Form. On postoperative day 1, DTI images of the high cervical spinal cord were obtained. DTI metrics were correlated with the number of ablations as well as early postoperative pain outcomes. RESULTS: Seven patients (4 male, mean age 53.8 ± 4.6 years) were studied. Fractional anisotropy of the hemicord was significantly lower on the side of the lesion as compared to the contralateral side (0.54 ± 0.03 vs. 0.63 ± 0.03, p < 0.001). Mean diffusivity correlated with the improvement in the VAS score at 1 week (r = 0.88, 95% CI = 0.34-1.00, p = 0.008), as well as the change in pain severity scores at 1 week (r = 0.99, 95% CI = 0.82-1.00, p < 0.001). CONCLUSION: DTI metrics are sensitive to the number of ablations as well as early improvement in pain scores after cordotomy. DTI of the cervical spinal cord is a potential biomarker of neural ablation after percutaneous cordotomy for intractable cancer pain.

Morbidity and mortality associated with hypernatremia in patients with severe traumatic brain injury.

OBJECTIVE Hypernatremia is independently associated with increased mortality in critically ill patients. Few studies have evaluated the impact of hypernatremia on early mortality in patients with severe traumatic brain injury (TBI) treated in a neurocritical care unit. METHODS A retrospective review of patients with severe TBI (admission Glasgow Coma Scale score ≤ 8) treated in a single neurocritical care unit between 1986 and 2012 was performed. Patients with at least 3 serum sodium values were selected for the study. Patients with diabetes insipidus and those with hypernatremia on admission were excluded. The highest serum sodium level during the hospital stay was recorded, and hypernatremia was classified as none (≤ 150 mEq/L), mild (151-155 mEq/L), moderate (156-160 mEq/L), and severe (> 160 mEq/L). Multivariate Cox regression analysis was performed to determine independent predictors of early mortality. RESULTS A total of 588 patients with severe TBI were studied. The median number of serum sodium measurements for patients in this study was 17 (range 3-190). No hypernatremia was seen in 371 patients (63.1%), mild hypernatremia in 77 patients (13.1%), moderate hypernatremia in 50 patients (8.5%), and severe hypernatremia in 90 patients (15.3%). Hypernatremia was detected within the 1st week of admission in 79.3% of patients (n = 172), with the majority of patients (46%) being diagnosed within 72 hours after admission. Acute kidney injury, defined as a rise in creatinine of ≥ 0.3 mg/dl, was observed in 162 patients (27.6%) and was significantly associated with the degree of hypernatremia (p < 0.001). At discharge, 148 patients (25.2%) had died. Hypernatremia was a significant independent predictor of mortality (hazard ratios for mild: 3.4, moderate: 4.4, and severe: 8.4; p < 0.001). Survival analysis showed significantly lower survival rates for patients with greater degrees of hypernatremia (log-rank test, p < 0.001). CONCLUSIONS Hypernatremia after admission in patients with severe TBI was independently associated with greater risk of early mortality. In addition to severe hypernatremia, mild and moderate hypernatremia were significantly associated with increased early mortality in patients with severe TBI.

A comparison of the recovery profiles of desflurane and isoflurane anesthesia in patients undergoing elective supratentorial craniotomy: A randomized controlled trial.

CONTEXT: Few studies have compared recovery profiles of desflurane and isoflurane for patients undergoing elective supratentorial craniotomy. It is not known if the choice of inhalational agent can affect the duration of transient postoperative neurological deficits in these patients. AIMS: To compare the effect of desflurane and isoflurane on time-to-emergence and time-to-recovery of transient postoperative neurological deficits in patients undergoing supratentorial craniotomy. SETTINGS AND DESIGN: Prospective, double-blinded, randomized controlled trial at a tertiary care hospital. METHODS AND MATERIALS: We randomly assigned 60 patients to receive either desflurane or isoflurane during elective supratentorial craniotomy for intra-axial mass lesions. Time-to-emergence and time-to-recovery of transient postoperative neurological deficits were recorded and compared. STATISTICAL ANALYSIS USED: Parametric variables were compared by the Student's t test. Baseline data was compared using Pearson's chi square test, Fisher's exact test and two proportion Z test. RESULTS: There was a 35.7%, 31.4% and 34.5% reduction in median times to eye opening, obeying commands and orientation in the desflurane group (n=27) as compared to the isoflurane group (n=28). Five patients were enrolled but not included for analysis-Twelve patients sustained transient neurological deficits after surgery (desflurane, n=3; isoflurane, n=9). No significant difference in the time-to-recovery of transient postoperative neurological deficits was observed. CONCLUSIONS: Desflurane significantly reduced emergence times, and was able to facilitate an early neurological examination for patients. Additional studies are required to establish the impact of inhalational agents on transient postoperative neurological deficits.

Severity of spinal cord injury influences diffusion tensor imaging of the brain.

BACKGROUND: The purpose of this study was to determine whether DTI changes in the brain induced by a thoracic spinal cord injury are sensitive to varying severity of spinal contusion in rats. METHODS: A control, mild, moderate, or severe contusion injury was administered over the eighth thoracic vertebral level in 32 Sprague-Dawley rats. At 11 weeks postinjury, ex vivo DTI of the brain was performed on a 9.4T Bruker scanner using a pulsed gradient spin-echo sequence. RESULTS: Mean water diffusion in the internal capsule regions of the brain and pyramid locations of the brainstem were correlated with motor function (r(2) = 0.55). Additionally, there were significant differences between injury severity groups for mean diffusivity and fractional anisotropy at regions associated with the corticospinal tract (P = 0.05). CONCLUSION: These results indicate that DTI is sensitive to changes in brain tissue as a consequence of thoracic SCI.

Thirty-day outcomes for posterior fossa decompression in children with Chiari type 1 malformation from the US NSQIP-Pediatric database.

PURPOSE: The multicenter National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database maintained by the American College of Surgeons was used to describe 30-day outcomes following Chiari type 1 decompression in children and to identify risk factors for readmission, reoperation, and perioperative complications. METHODS: We identified patients aged 0-18 years who underwent posterior cranial fossa decompression for Chiari type 1 malformation in 2012, 2013, and 2014 in the NSQIP-Pediatric database. Multivariate regression analysis was performed using preoperative and perioperative data to determine risk factors for perioperative adverse events within 30 days of the index procedure. RESULTS: We identified 1459 patients from the NSQIP-P database for the years 2012-2014. Fifty-five percent of the patients were female. Mean age was 9.8 years (median 10 years). Median operative time was 141 min (IQR 107-181 min). Postoperative complications were noted in 5.3 % and unplanned reoperations in 3.4 % of the patients. Postoperative ventriculoperitoneal shunt placement occurred in 0.9 % of the patients. Wound problems were the most common complication (3.8 % of all patients). Univariate analysis showed the following factors were associated with perioperative adverse events: longer operative times, hospital stay ≥5 days, hydrocephalus, and neurological, renal, and congenital comorbidities. On multivariate analysis, female sex (OR 1.46, 95 % CI 1.01-2.11), increased operative time (OR 1.01, 95 % CI 1.00-1.01), and hospital stay ≥5 days (OR 2.62, 95 % CI 1.55-4.43) were independent factors associated with perioperative adverse events. CONCLUSION: The NSQIP-P database was used to describe surgical outcomes of posterior cranial fossa decompression in a US nationwide sample of 1459 children with Chiari type 1 malformation. The overall recorded adverse rate was low. Longer operative times and length of hospital stay ≥5 days during the index admission were associated with perioperative adverse events.

Clinical adjacent-segment pathology after central corpectomy for cervical spondylotic myelopathy: incidence and risk factors.

OBJECTIVE The goal of this study was to investigate the prevalence and risk factors of clinical adjacent-segment pathology (CASP) following central corpectomy for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL). METHODS The authors reviewed 353 cases involving patients operated on by a single surgeon with a minimum 12-month follow-up after central corpectomy for CSM or OPLL between 1995 and 2007. Patients with symptoms consistent with CASP at follow-up were selected for the study. The authors analyzed the prevalence and risk factors for CASP after central corpectomy for CSM/OPLL. RESULTS Fourteen patients (13 male, 1 female; mean age 46.9 ± 7.7 years) were diagnosed with symptoms of CASP (3.9% of 353 patients) at follow-up. The mean interval between the initial surgery and presentation with symptoms of CASP was 95.6 ± 54.1 months (range 40-213 months). Preoperative Nurick grades ranged from 2 to 5 (mean 3.5 ± 1.2), and the Nurick grades at follow-up ranged from 1 to 5 (mean 3.0 ± 1.3, p = 0.27). Twelve patients had myelopathic symptoms and 2 had radiculopathy at follow-up. Patients with poorer preoperative Nurick grades had a higher risk for development of CASP (HR 2.6 [95% CI 1.2-5.3], p = 0.01). CONCLUSIONS In the present study, CASP was seen in 3.9% of patients following central corpectomy for CSM/OPLL. The risk of CASP after central corpectomy for CSM/OPLL was higher in patients with poorer preoperative Nurick grades.

Visual recovery after surgical decompression of an occipital intraventricular cyst.

: A 62-year-old woman presented with a chronic left homonymous visual field defect because of a right occipital cyst. Serial visual field examination documented stable visual fields for 12 months, after which there was worsening of visual fields associated with enlargement of the cyst. Surgical decompression of the occipital cyst resulted in marked improvement of the visual field defect over 9 months. This case demonstrates that surgical decompression of cystic lesions adjacent to posterior visual pathways can result in recovery of chronic visual field loss.

Complex Neck Loading and Injury Tolerance in Lateral Bending With Head Rotation From Human Cadaver Tests.

Advancements in automated vehicles may position the occupant in postures different from the current standard posture. It may affect human tolerance responses. The objective of this study was to determine the lateral bending tolerance of the head-cervical spine with initial head rotation posture using loads at the occipital condyles and lower neck and describe injuries. Using a custom loading device, head-cervical spine complexes from human cadavers were prepared with load cells at the ends. Lateral bending loads were applied to prerotated specimens at 1.5 m/s. At the occipital condyles, peak axial and antero-posterior and medial-lateral shear forces were: 316-954 N, 176-254 N, and 327-508 N, and coronal, sagittal, and axial moments were: 27-38 N·m, 21-38 N·m, and 9.7-19.8 N·m, respectively. At the lower neck, peak axial and shear forces were: 677-1004 N, 115-227 N, and 178-350 N, and coronal, sagittal, and axial moments were: 30-39 N·m, 7.6-21.3 N·m, and 5.7-13.4 N·m, respectively. Ipsilateral atlas lateral mass fractures occurred in four out of five specimens with varying joint diastasis and capsular ligament involvements. Acknowledging that the study used a small sample size, initial tolerances at the occipital condyles and lower neck were estimated using survival analysis. Injury patterns with posture variations are discussed.

Subclinical respiratory dysfunction and impaired ventilatory adaptation in degenerative cervical myelopathy.

Degenerative cervical myelopathy (DCM) is a debilitating neurological condition characterized by chronic compression of the cervical spinal cord leading to impaired upper and lower limb function. Despite damage to areas of the cervical spinal cord that house the respiratory network, respiratory dysfunction is not a common symptom of DCM. However, DCM may be associated with respiratory dysfunction, and this can affect the ventilatory response to respiratory challenges during emergence from anesthesia, exercise, or pulmonary disease. Surgical spinal cord decompression, which is the primary treatment for DCM, leads to improved sensorimotor function in DCM; yet its impact on respiratory function is unknown. Here, using a clinically relevant model of DCM, we evaluate respiratory function during disease progression and assess adaptive ventilation to hypercapnic challenge before and after surgical intervention. We show that despite significant and progressive forelimb and locomotor deficits, there was no significant decline in eupneic ventilation from the early to late phases of spinal cord compression. Additionally, for the first time, we demonstrate that despite normal ventilation under resting conditions, DCM impairs acute adaptive ventilatory ability in response to hypercapnia. Remarkably, akin to DCM patients, surgical decompression treatment improved sensorimotor function in a subset of mice. In contrast, none of the mice that underwent surgical decompression recovered their ability to respond to hypercapnic ventilatory challenge. These findings underscore the impact of chronic spinal cord compression on respiratory function, highlighting the challenges associated with ventilatory response to respiratory challenges in individuals with DCM. This research highlights the impact of cervical spinal cord compression on respiratory dysfunction in DCM, as well as the persistence of adaptive ventilatory dysfunction after surgical spinal cord decompression. These results indicate the need for additional interventions to enhance recovery of respiratory function after surgery for DCM.

Impact of postsurgical rehabilitation on outcomes for degenerative cervical myelopathy.

OBJECTIVE: Despite widespread use, there is limited evidence to support postsurgical rehabilitation to enhance neurological recovery after surgery for degenerative cervical myelopathy (DCM). Outcomes research for DCM seldom accounts for the effect of postsurgical rehabilitation. The aim of this study was to quantify the impact of postsurgical rehabilitation on outcomes after surgery for DCM. METHODS: This was a retrospective analysis of prospectively collected data from a single center. The study enrolled 66 patients who underwent spinal surgery for DCM. In addition to patient demographic, imaging, and surgical data, chart review was performed to document the timing, type, duration, and outcomes of postsurgical rehabilitation therapy. Outcomes were collected prospectively, including the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI) score, and SF-36 physical component summary (PCS) score. Linear regression models were created to determine the independent effects of type and timing of postsurgical occupational therapy (OT) and physical therapy (PT) on outcomes. RESULTS: A total of 66 patients were included in the analysis. Multivariate regression analysis showed that postsurgical OT was associated with significantly greater improvement in 12-month SF-36 PCS scores (p = 0.009) and mJOA scores (p = 0.019). In the subset of patients who received therapy, delayed therapy (> 42 days after surgery) compared to early therapy (< 42 days after surgery) was associated with less improvement in SF-36 PCS scores (p = 0.03). CONCLUSIONS: Postsurgical outpatient rehabilitation was independently associated with improved postsurgical outcomes within the 1st year after surgery for DCM, and early therapy (< 42 days) was associated with superior outcomes compared to delayed therapy. This is one of the first studies to use a prospective database to demonstrate an independent effect for postsurgical rehabilitation on outcomes after surgery for DCM.

Interventions to Optimize Spinal Cord Perfusion in Patients With Acute Traumatic Spinal Cord Injury: An Updated Systematic Review.

STUDY DESIGN: Systematic review update. OBJECTIVES: Interventions that aim to optimize spinal cord perfusion are thought to play an important role in minimizing secondary ischemic damage and improving outcomes in patients with acute traumatic spinal cord injuries (SCIs). However, exactly how to optimize spinal cord perfusion and enhance neurologic recovery remains controversial. We performed an update of a recent systematic review (Evaniew et al, J. Neurotrauma 2020) to evaluate the effects of Mean Arterial Pressure (MAP) support or Spinal Cord Perfusion Pressure (SCPP) support on neurological recovery and rates of adverse events among patients with acute traumatic SCI. METHODS: We searched PubMed/MEDLINE, EMBASE and ClinicalTrials.gov for new published reports. Two reviewers independently screened articles, extracted data, and evaluated risk of bias. We implemented the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to rate confidence in the quality of the evidence. RESULTS: From 569 potentially relevant new citations since 2019, we identified 9 new studies for inclusion, which were combined with 19 studies from a prior review to give a total of 28 studies. According to low or very low quality evidence, the effect of MAP support on neurological recovery is uncertain, and increased SCPP may be associated with improved neurological recovery. Both approaches may involve risks for specific adverse events, but the importance of these adverse events to patients remains unclear. Very low quality evidence failed to yield reliable guidance about particular monitoring techniques, perfusion ranges, pharmacological agents, or durations of treatment. CONCLUSIONS: This update provides an evidence base to support the development of a new clinical practice guideline for the hemodynamic management of patients with acute traumatic SCI. While avoidance of hypotension and maintenance of spinal cord perfusion are important principles in the management of an acute SCI, the literature does not provide high quality evidence in support of a particular protocol. Further prospective, controlled research studies with objective validated outcome assessments are required to examine interventions to optimize spinal cord perfusion in this setting.

Characterization and limitations of diffusion tensor imaging metrics in the cervical spinal cord in neurologically intact subjects.

PURPOSE: To characterize diffusion tensor imaging (DTI) metrics across all levels of the cervical spinal cord (CSC) and to study the impact of age and signal quality on these metrics. MATERIALS AND METHODS: DTI metrics were calculated for gray matter (GM) and white matter (WM) funiculi throughout the CSC (C1-T1) in 25 healthy subjects (22-85 years old). Signal-to-noise ratios (SNRs) and mean DTI metrics were measured for the upper (C1-3), middle (C4-6) and lower (C7-T1) cervical segments. Age-related changes in DTI metrics were analyzed for the individual segment groups. RESULTS: Fractional anisotropy (FA), mean diffusivity (MD) and transverse apparent diffusion coefficient (tADC) showed significant differences between GM and WM funiculi. Significant age-related changes were observed in FA in upper and middle CSC segments but not in the lower CSC. The median SNR was significantly lower in the middle and lower segment groups as compared to the upper levels, contributing to poor spatial resolution in these regions. CONCLUSION: This study provides DTI data for GM and WM funiculi throughout the CSC. While DTI metrics may be used to define cord pathology, variations in metrics due to age and signal quality need to be accounted for before making definitive conclusions.

Does the type of T2-weighted hyperintensity influence surgical outcome in patients with cervical spondylotic myelopathy? A review.

PURPOSE: To review the literature on different classifications of T2-weighted (T2W) increased signal intensity (ISI) on preoperative magnetic resonance (MR) images of patients with cervical spondylotic myelopathy (CSM). METHODS: The authors searched the databases of PubMed and Cochrane for studies that used a categorization of T2W ISI to predict the functional outcome after decompressive surgery for CSM. Selected studies were analyzed for the type of ISI classification used, patient selection, methodology and results. The level of evidence provided by each study was determined. RESULTS: Twenty-two studies fulfilled our search criteria. There were 11 prospective studies and a total of 1,508 patients were studied. The majority of studies classified ISI based on either the longitudinal extent (12 studies) or the qualitative features of the ISI (10 studies). Three studies used both parameters to classify T2W ISI. Other classifications were based on the position of ISI (1 study), presence of snake-eye appearance on axial MR images (1 study) and signal intensity ratio (SIR) (1 study). Poorer functional outcomes correlated with sharp, intense ISI (6 studies) and multisegmental ISI (5 studies) (Class II evidence). Five of ten studies reported that the regression of ISI postoperatively was associated with better neurological outcomes (Class II evidence). CONCLUSIONS: Methodological variations in previous studies made it difficult to compare studies and results. Both multisegmental T2W ISI and sharp, intense T2W ISI are associated with poorer surgical outcome (Class II evidence). The regression of T2W ISI postoperatively correlates with better functional outcomes (Class II). Future studies on the significance of ISI should ensure use of a uniform grading system, standardized outcome measures and multivariate analyses to control for other preoperative variables.